Nokea
Which of the following findings would suggest pneumothorax in a trauma victim?
- A. Pronounced crackles.
- B. Inspiratory wheezing.
- C. Dullness on percussion.
- D. Absent breath sounds.
Correct Answer: D
Rationale: Absent breath sounds on the affected side suggest pneumothorax due to air in the pleural space. Crackles, wheezing, and dullness are more indicative of other conditions.
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A client who has had a lumbar laminectomy with a spinal fusion is sitting in a chair. In which position are his feet if he is complying with his postoperative instructions?
- A. On the floor with the feet flat.
- B. On a low footstool.
- C. In any comfortable position with legs uncrossed.
- D. On a high footstool so the feet are level with the chair seat.
Correct Answer: A
Rationale: Feet flat on the floor maintain neutral spine alignment, reducing strain on the surgical site.
A client is admitted with a myocardial infarction and new onset atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as:
- A. Heart rate irregular with S3.
- B. Heart rate irregular with S4.
- C. Heart rate irregular with aortic regurgitation.
- D. Heart rate irregular with mitral stenosis.
Correct Answer: A
Rationale: An extra heart sound after S2 at the apex, constant through the respiratory cycle, is an S3, often associated with heart failure post-myocardial infarction. Atrial fibrillation causes an irregular heart rate.
Which of the following interventions will be most effective in improving transcultural communications with the client?
- A. Use touch to show concern and caring for the client.
- B. Focus attention on verbal communication skills only.
- C. Establish a rapport and listen to their concerns.
- D. Maintain eye contact at all times.
Correct Answer: C
Rationale: Establishing rapport and listening to concerns fosters trust and understanding, which are essential for effective transcultural communication.
Which of the following is a late symptom of polycythemia vera?
- A. Headache.
- B. Dizziness.
- C. Pruritus.
- D. Shortness of breath.
Correct Answer: C
Rationale: Pruritus, especially after warm baths, is a late symptom of polycythemia vera due to increased histamine release from elevated basophils. Headache, dizziness, and shortness of breath are earlier symptoms related to increased blood viscosity and hypermetabolism.
Following a thoracotomy, the client has severe pain. Which of the following strategies for pain management will be most effective for this client?
- A. Repositioning the client immediately after administering pain medication.
- B. Reassessing the client 30 minutes after administering pain medication.
- C. Verbally reassuring the client after administering pain medication.
- D. Readjusting the pain medication dosage as needed according to the client's condition.
Correct Answer: D
Rationale: Readjusting pain medication dosage based on the client's condition ensures adequate pain control, critical for recovery. Repositioning, reassessing, and reassurance are supportive but less effective alone.